Tuesday, August 21, 2012

Work at HAH and the Orphanages Continue

Aug 8

The Wednesday clinic looked huge.  Of course, the CURE clubfoot clinic helped fill the hallway.  We didn’t need to see any of those patients but it meant we had one less room in which to evaluate our general ortho patients.  Eric, Randy and Francel began seeing patients in the available rooms/hallway.  I took advantage of the opportunity to do some emailing.  I am hoping to arrange for Wilfredo Perez to come for a few days from the Adventist hospital in Puerto Rico to get the anesthesia machines all working properly again.  Hopefully he will be able to check and diagnose the problem with the Digital xray machine also.  I then met with the new medical director of the hospital, Dr Franck Geneous.  His medical training and masters degree in public health were done here in Haiti.  He has worked in several different countries for UNICEF, most recently here in Haiti.  He expressed deep appreciation to us for coming and working at HAH.  The board and administration have a strong desire for HAH to be a flagship hospital with orthopedic surgery the principal focus.  We discussed the importance of improving leadership in the area of surgical services.  The area of maintenance, especially biomedical technology, was also addressed.  The board recently voted to change leadership in the operating room and add additional responsibility for all perioperative care.  Marie Paul will have those responsibilities.  Some weak efforts have been made to have a person with some training in Biomedical Tech available to address problems in the hospital.  We talked about partnering with Bella Vista Hospital in Puerto Rico.  Wilfredo Perez spent 3 days with us last year mainly checking and restoring the anesthesia machines in all 3 rooms.  He is willing to participate in a training program and assist in developing a department.  The crucial items from an orthopedic standpoint are the anesthesia machines, the corresponding monitors, the C-arm image intensifier, the digital xray machine and the arthroscopy equipment.  The development of adequate laboratory facilities has been placed on hold.  There are plans to refocus on that important area beginning next week.

Daniel Williams is a new member of the administrative team at HAH.  He attended the meeting with Dr Geneous.  He came to the hospital via Johaniter but is now salaried by the hospital.  He is an experienced administrator from Grenada.  I was very impressed with his ability to quickly grasp the importance of the areas that need to be emphasized for the orthopedic program to flourish.  One idea of his is to develop a waste treatment incinerating capability.  It could serve the needs of the hospital as well as provide service to other companies.  It could be a revenue center for the hospital.

I explained to both of them the importance of continuing the orthopedic program for indigents.  Both Dr Nelson and I, as well as virtually all of the members of the orthopedic teams will continue to be involved as long as the program emphasizes providing care for the poor.  We discussed at length the challenges of covering the hospital costs.  Certainly a system needs to be developed that can adequately assess the financial resources of patients and their families.  Those that have resources should help cover the costs involved.  I also explained the money raising for the Haiti Indigent Patient Fund.  Both Dr Geneous and Daniel are very interested in cooperating to finish the project and start using the funds.  Dr Geneous put me in contact with Monty Jacobs at Florida Hospital.  Their foundation may be able to supply some matching funds.  They can supply us with financial expertise to develop the endowment and maximize the interest.

I felt the meeting was very worthwhile.  It will be interesting to see if decisions and actions will happen sooner rather than later.
Both bone forearm fracture repair

We had several smaller cases to do as well.  The last case was a patient with fractures both bones of the forearm.  I assisted Randy and he did a slick job.

All of the team members wanted to go out tonight so we loaded up and headed to the Hotel Oluffson.  The traffic was really bad.  It took more than an hour to get there.  It can take as little as 15 minutes.  We all enjoyed the evening.  The building is an old Victorian that has survived the disasters that have afflicted Haiti.  It makes me think of the movie “Casablanca.”  The traffic home was almost nonexistent and it took only 20 minutes.

9 August 2012

We had 13 cases on the board for today.  A couple didn’t show and we had to cancel another two.  We wound up doing 9 of them.  I started with a little boy with a spastic equinovarus foot.  I did a TAL and fractional lengthening of the Post Tibialis.  Francel and Eric planned to start with a child with genu varum and put in 8 plates.  The C-arm wouldn’t boot up so the patient had to be awakened from anesthesia.  I looked at the machine but it wasn’t giving an error code on the screen so I was stumped.  We carried on with other cases including 2 knee arthroscopies that Eric did with Francel.  The first had a classic bucket handle tear of the medial meniscus.  It was a great teaching case.  The second arthroscopy went well also.  Meanwhile, Samuel had managed to get the C-arm working.  Apparently, it was the same problem that had happened when Scott was here in June.  He had given Samuel a picture of the back of the monitor with exactly what to do.  It worked!  Francel proceeded with the 8 plate case.

All of the cases went well.  We were all pretty tired so just snacked for dinner and went to bed early.

10 Aug

The schedule was lighter today.  The clinics on Fridays are commonly smaller.  Eric went with Mary and Katie to the orphanage project so Francel, Randy and I made rounds then dove into the clinic.  We finished at 10 am and then had 2 cases in the OR.  The ORs were occupied with Gyn and general surgery cases to start the day.  Randy did a leg split thickness skin graft.   Francel and I did another knee arthroscopy.  It was great to see that Francel has made progress with his arthroscopic skill.  It took over an hour for him to get good visualization, inspect all of the intraarticular structures and then deal with the torn lateral meniscus and the unstable femoral chondromalacia.  If he had regular anesthesia, he could schedule a lot of cases and improve a lot faster.

 We all grabbed some lunch then got on the small bus that Emmanuel had arranged.  Our outing to the mountains was a lot of fun.   Four of the translators and Franz, the xray tech, came along.  Everybody had a good time.  We shopped for art in Fermathe.  I found a couple of really nice rock carvings.  Jeannie really likes the bust of a young Haitian lady.  My favorite, by far, is a very featured somewhat disfigured face of a Haitian man.  It tells me so much about what Haitians have experienced – the poverty, violence, pain and loss.

We spent another hour or more at Ft Jacques.  A nice young man gave us a tour.  He was very knowledgeable.  We enjoyed a watermelon in the parking lot also.  We hustled back down the mountain to Delmas for our dinner appointment with the Brice family.  This was either the 4th or 5th dinner they have made for us.  His daughter had severe bowlegs from Blounts disease.  We put on bilateral Taylor Spatial frames and corrected her.  She and her family are so grateful.  Her father told me on one of the times we went to her house for dinner that he would give me Haiti if he could.  They had the usual tremendous spread.  We all filled ourselves totally.

Returning to the hospital we encountered traffic at least as bad as we endured on Wednesday on our way to the Oluffsson hotel.  The 30 minute trip took an hour and a half.

11 August 2012

Our bus was scheduled to leave for the Dominican Republic at 8 am.  We got up at 5 so we could leave by 6.  Ericksons and Katie had a 10 am flight so we all went together.  The bus station isn’t far from the airport.  They filled us in on their eventful day yesterday.  The projects at Mary Lou’s orphanage were all successfully completed.

1.  New steps up the very steep hill from the street
2.  Dedicated clean sweet water supply with large storage tank including tap in the kitchen area
3.  Improved play area
4.  Improved cooking facility
5.  supply of rice and beans that should last a month or more
 6.  Porcelain toilet

They were so excited about the whole project.  When the water was turned on late in the afternoon they had a celebration and threw buckets of water over all of the kids.  It is an unbelievably satisfying experience to provide poor Haitians with these things that we take so for granted in the US.  It really brings one a level of personal happiness that cannot be obtained in virtually any other way.

Thursday, August 16, 2012

An Article from the NY Times on Haiti

Years After Haiti Quake, Safe Housing Is a Dream for Many

Today, the New York Times published the above article about the current state of housing for those displaced by the earthquake.  It is worth reading and sharing to continue to get word out about the tremendous needs in Haiti. 

Tuesday, August 14, 2012

The Dietrichs Return to Haiti

Another team embarked on a week long trip to Hopital Adventiste d'Haiti from August 6-10. Team members came from Utah, Minnesota, Wisconsin, Florida, Illinois and the Dominican Republic to Haiti Adventist Hospital on August 5, 2012.  The orthopedic medical team goals were evaluating and treating patients with orthopedic conditions and continue with advanced orthopedic training for Dr Francel Alexis.

Team Members
Orthopedic Surgeons
        Eric Erickson MD
        Randolph Knight MD
        Terry Dietrich MD

Anesthesia Providers
        Jacob Rick CRNA
        Karen Stagg CRNA

Nursing/OR specialists
         Jeannie Dietrich RN
         Lucia Hernandez RN
         Elinore Shank RN
         Taylor Drake

Orphanage program/ Support/ Photography
         Mary Erickson
         Katie Kaminsky
         Pam Knight

5 Aug
Team members found the assigned hospital accommodations.  The small building built by Project Hope next to the rehabilitation building has been equipped with air conditioning and 6 bunk beds.  There is a single bathroom in the building.  Other bathrooms are available in the nearby rehab building as well as in the hospital.  The “new wing” of the hospital that formerly accommodated the long term volunteers has been nicely remodeled and is nearly ready to be opened for patient care.  The mezzanine area formerly used as sleeping space for short term volunteers has been divided into four offices and is used for classes and training and office space.  Long term volunteers now are occupying the renovated duplexes.  A chain link fence with locking gate separates those two buildings from the remainder of the campus.  The only remaining long term volunteer from our year here is Marc.  She coordinates the different training programs.   Two long term volunteers from Germany are involved in the rehab program.  Jeannie and I arranged for the whole team to have pizza and salads at the Auberge.  Eric and I cooled off in the pool for a few minutes when I took them to check in.  I also ordered the food ahead of time so we wouldn’t have such a long wait.  It worked out great.  Emmanuel and JJ came with us to eat at the hotel.  It is great to see them again.

6 Aug
Dr Alexis met us after the morning worship/orientation and we began the workday.  Only 2 orthopedic patients were in the hospital.  One is an elderly patient with a pressure ulcer on her hip.  The other had a femoral neck fracture  and Dr Alexis did a hemiarthroplasty.  Francel had scheduled several smaller cases for a bit later so we all started seeing patients in the clinic.  It was a big clinic and we saw lots of good cases.  Both Eric and Randy had no problem evaluating and making decisions on patients.  We used both of our regular rooms for seeing patients as well as the xray room since the digital machine isn’t working.  Since there are four of us, I got a fan and some chairs and evaluated quite a few patients in the hallway.  We must have seen nearly 10 patients with frames of all types.  They were mainly done by superspecialists like John Herzenberg, Dror Paley and , of course, Scott Nelson in the last several months.   All of the patients with frames were doing very well.  We saw the usual mix of children with bowlegs, knockknees, clubfeet and adults with fractures both new and old.  There were several cases of infections as well, some of them post op.  The surgical cases were hardware removals and the decubitus ulcer debridement with wound vac.  Mary and Katie returned from the orphanage project very excited.  I’ll include Mary’s comments.

Jeannie and others exchanged their OR garb for chefs hats and whipped up a tasty spaghetti dinner for the whole team.

7 Aug
Francel and I did a recurrent clubfoot case to start the day. He seemed more self assured doing the case than I have seen in the past.  That is a very good sign.

Francel, Randy and I then did a 14 year old boy with bilateral Blounts.  I was impressed with Francel’s initiative in doing the case.  He was a fairly small child and we couldn’t do both sides simultaneously.  Francel did a very careful and thorough job on both sides.  The osteotomies went well.  We will have to get good orthogonal xrays and then measure the deformity as well as the mounting parameters for both frames then enter all the data on the internet.  I never cease to be amazed that this type of complex corrective surgery is being done on a regular basis here in Haiti.  The cost would be prohibitive if the frames would have to be purchased.



Eric and Francel do a shoulder arthroscopy
 Eric did a shoulder arthroscopy on a young man with recurrent shoulder dislocation.  The patient told me it had dislocated “a hundred times.”  Eric wasn’t intimidated in the least by our minimalist arthroscopy equipment and did his usual impressively efficient setup.  He found a large Hill-Sachs lesion and did the corresponding repair.  He made it look easy.  He is a good teacher and spent time explaining things to Francel.  We have at least two patients with knees that need to be scoped.  Francel can benefit a lot from Eric’s expertise and knowledge. We had a bilateral recurrent clubfoot case that Francel had scheduled for posterior medial release but I didn’t think we should do it.  He hadn’t done any preop casting and I was sure that the patient would need several cast changes with manipulations post op.  There won’t be anesthesia available for that.  We manipulated and casted her.  Francel will continue to cast in the clinic.  The feet are so rigid they almost seem like arthrogryposis but the child has no other joints involved.

Eric took off some frames today as well.  Our last case was a young man with an infected femur fracture.  He had an antibiotic coated SIGN nail that was put in last year.  He had 3 locking screws and the nail that all came out fairly easily.  We excised the fistulas and removed nonviable bone as well as infected tissue from the canal.  The tobramycin methacrylate beads were placed in and around the canal.  If the infection can be cleared up, he will need a bone graft and IM rodding again.

Jeannie made her famous vegeburgers tonight so we had a real feast.